Contexte : Les médecins spécialistes peuvent participer aux soins ambulatoires des personnes atteintes de maladies chroniques (MCs) et comorbidité comme co-gestionnaire ou consultant selon qu’ils sont responsables ou non du suivi du patient. Il y a un manque d’évidences sur les déterminants et l’impact du type d’implication du médecin spécialiste, ainsi que sur la façon optimale de mesurer la comorbidité pour recueillir ces évidences. Objectifs : 1) déterminer chez les patients atteints de MCs les facteurs associés à la cogestion en spécialité, dont les caractéristiques des organisations de première ligne et la comorbidité; 2) évaluer si le type d’implication du spécialiste influence le recours à l’urgence; 3) identifier et critiquer les méthodes de sélection d’un indice de comorbidité pour la recherche sur l’implication des spécialistes dans le suivi des patients. Méthodologie : 709 adultes (65 +/- 11 ans) atteints de diabète, d’arthrite, de maladie pulmonaire obstructive chronique ou d’insuffisance cardiaque furent recrutés dans 33 cliniques de première ligne. Des enquêtes standardisées ont permis de mesurer les caractéristiques des patients (sociodémographiques, comorbidité et qualité de vie) et des cliniques (modèle, ressources). L’utilisation des services de spécialistes et de l’urgence fut mesurée avec une base de données médico-administratives. Des régressions logistiques multivariées furent utilisées pour modéliser les variables associées à la cogestion et comparer le recours à l’urgence selon le type d’implication du spécialiste. Une revue systématique des études sur l’utilisation des services de spécialistes, ainsi que des revues sur les indices de comorbidité fut réalisée pour identifier les méthodes de sélection d’un indice de comorbidité utilisées et recommandées. Résultats : Le tiers des sujets a utilisé les services de spécialistes, dont 62% pour de la cogestion. La cogestion était associée avec une augmentation de la gravité de la maladie, du niveau d’éducation et du revenu. La cogestion diminuait avec l’âge et la réception de soins dans les cliniques avec infirmière ayant un rôle innovateur. Le recours à l’urgence n’était pas influencé par l’implication du spécialiste, en tant que co-gestionnaire (OR ajusté = 1.06, 95%CI = 0.61-1.85) ou consultant (OR ajusté = 0.97, 95%CI = 0.63-1.50). Le nombre de comorbidités n’était pas associé avec la cogestion, ni l’impact du spécialiste sur le recours à l’urgence. Les revues systématiques ont révélé qu’il n’y avait pas standardisation des procédures recommandées pour sélectionner un indice de comorbidité, mais que 10 critères concernant principalement la justesse et l’applicabilité des instruments de mesure pouvaient être utilisés. Les études sur l’utilisation des services de spécialistes utilisent majoritairement l’indice de Charlson, mais n’en expliquent pas les raisons. Conclusion : L’implication du spécialiste dans le suivi des patients atteints de MCs et de comorbidité pourrait se faire essentiellement à titre de consultant plutôt que de co-gestionnaire. Les organisations avec infirmières ayant un rôle innovateur pourraient réduire le besoin pour la cogestion en spécialité. Une méthode structurée, basée sur des critères standardisés devrait être utilisée pour sélectionner l’indice de comorbidité le plus approprié en recherche sur les services de spécialistes. Les indices incluant la gravité des comorbidités seraient les plus pertinents à utiliser. / Background: Medical specialist physicians can be involved either as comanagers (responsible for follow-up of patients) or consultants (provide advice/specialized interventions) in the care of patients with chronic diseases (CDs) managed in a primary health care (PHC) setting. Evidences concerning determinants and impact of type of specialist involvement are currently lacking, in particular the influence of comorbidity and how best to measure this factor. Objectives: The objectives were 1) to determine clinical, patient and PHC organizational characteristics associated with type of specialist involvement in patients with CDs; 2) to assess whether type of specialist involvement is associated with emergency department (ED) use and; 3) to identify methods for selecting a comorbidity index for specialist services research. Methods: 709 adults (65 +/- 11 years) with diabetes, heart failure, arthritis, or chronic obstructive pulmonary disease were recruited in 33 PHC practices. Standardized surveys were used to measure patient (gender, age, education, income, comorbidity, quality of life) and practice characteristics (model, remuneration mode, resources, role of nurse). Information on specialist services and ED use was procured from the Quebec physician claims database. We used multivariate logistic regression to 1) model variables associated with being comanaged and 2) compare ED use among persons with different types of specialist involvement. We conducted two systematic reviews: 1) review articles on comorbidity indices to identify proposed selection procedures and 2) studies on specialist services utilization to identify selection processes actually used. Results: One third of our sample saw a specialist; the majority (62%) was as a comanager. Comanagement was associated with higher disease severity, younger age, higher education level and income and primary care management in practices without a nurse in advanced practice role. There was no difference in rates of ED use over one year between patients with or without specialist involvement, either as a comanager (adjusted OR = 1.06, 95%CI = 0.61-1.85) or as a consultant (adjusted OR = 0.97, 95%CI = 0.63-1.50). Quantity of comorbidity was not associated with either comanagement or impact of specialist involvement on ED use. Our systematic review revealed no standardized selection process of a comorbidity index. However, 10 distinct criteria related to accuracy and applicability of a measurement scale or validity of reported studies were compiled. Studies on specialist services utilization mostly used the Charlson comorbidity index, but none justified their choice. Conclusion: Specialist support in the management of patients with CDs and comorbidity should be provided on a consultant basis. The PHC practice model with a nurse in an advanced practice role may reduce the need for specialist comanagement. When adjusting for comorbidity, researchers should use a structured process to select the appropriate index based on standard criteria such as validity and applicability. Indices considering severity of comorbidities may be more useful than sole disease count in specialist services research.

The main objective of the study was to determine the exchange rate volatility regime for carry trade profitability when using the South African Rand as the target currency. The study used the Logistic Smooth Transition Regression (LSTR) model to test the uncovered interest rate parity (UIP). The Sharpe ratio and the risk adjusted forward premium were used as the transition variables. The transition variable is a function of the transition function, which is used to determine the regime for the UIP. The LSTR model is characterised by three regimes, i.e. the lower regime, the middle regime and the upper regime. The LSTR model was tested for the short-term forward rate maturity of less than one year. The results show that the UIP hypothesis holds in the middle regime for the Rand/USD and the Rand/GBP when using the Sharpe ratio as the transition variable. Meanwhile, the UIP hypothesis does not hold for the Rand/Yen when using the Sharpe ratio as the transition variable for the forward rate maturity of one month, and it does hold for other short-term forward rate maturity of less than one year. The results for the risk adjusted forward premium as the transition variable show that the UIP hypothesis does not hold for all three currencies at various short-term forward rate maturities of less than one year. The research provides the following contributions to new knowledge: (1) Uncovered interest parity hypothesis holds in the middle regime for all periods for the Rand/USD and the Rand/GBP when using the Sharpe ratio as the transition variable with a short-term forward rate maturity of less than one year. (2) Currency carry trade profit taking for the Rand/USD and the Rand/GBP can be achieved in the upper regime. (3) The results for the Rand/Yen are mixed, in that the UIP hypothesis does not hold for other crisis periods as a result of negative Sharpe ratios. However, for the calm periods, UIP hypothesis holds in the middle regime for the Rand/Yen for short-term forward rate maturity of more than one month but less than one year when using the Sharpe ratio as the transition variable. The overall contribution of this study is that for the South African Rand as the target currency, the UIP hypothesis holds for the short-term horizon when using the Sharpe ratio as the transition variable and that this mostly depends more on currency than on horizon. Contrary to other researchers who found that the UIP holds in the long-term maturity with higher Sharpe ratios in the upper regime, this study proved that the UIP holds in the short-term maturity horizon. / Business Management / D.B.L.

基金經理人與投資人間的代理問題起源於兩者目標的不一致，前者要求個人薪酬財富的極大化，後者要求投資組合價值的極大化。造成目標歧異的原因有兩個：其一是在資訊不對稱的環境下，投資人無法觀察到經理人投資組合是否真正從投資人利益角度出發，因此引發了經理人的道德危險；其二是在競爭激烈的基金產業□，年度定期績效評比結果與經理人薪酬紅利多寡相連結等制度的設計，加重經理人選擇持有一個高風險投資組合的逆誘因，特別是期中累積績效較差的輸家，隨著年終總績效結算日期的接近，在自利動機的驅使下可能會透過較高的操作風險調整幅度，企圖扭轉頹勢以求反敗為勝。 本研究首先利用卡方檢定、t檢定與Logistic迴歸模式，實證國內基金經理人是否具有自利性風險調整的行為傾向，接著從契約設計的觀點，以理論模式推導命題的方式，探討三種不同型態的誘因費契約對於抑制經理人自利性風險調整行為的作用，並間接利用問卷調查的方式來驗證其效果。研究的結果發現： 1.國內基金經理人不管是贏家或輸家，在越接近年終總績效的結算時，都會偏向選擇一個高風險的操作水準，同時，上述特性在非外資型投信公司所發行的基金、新基金、小規模基金、資淺經理人所操盤的基金特別明顯。 2.基金投資人對於季等短期績效的過分重視，是導致國內經理人操作風險調整幅度偏高的主要原因之一。 3.純粹誘因費契約以及只加上「上限條款」設計的契約，這兩種契約都無法抑制經理人冒高風險的傾向；而純粹誘因費契約加上「懲罰條款」的設計，有抑制經理人自利性調高操作風險行為的效果。 本研究成果的貢獻主要有兩點： 1.在政策應用上，本研究提出契約條款設計的理念，對於我國擬開放勞退等大型基金委託代客操作，雙方契約該如何設計以確保投資人的權益，有相當參考的價值，本研究同時也對投信公司、基金經理人等提出相關的制度性建議。 2.在理論推導上，本研究融合一般化均衡分析法與選擇權理論的應用，將不同型態的誘因費契約化成經理人向投資人所購買的歐式買權，標的資產為經理人所持投資組合的價值，履約價格為比較基準指數的價值，執行日期為一年期的績效評比，模型導証的重點是經理人所選擇投資組合的風險程度與該類比選擇權價值的關係。 / An important question for the contracting literature is the extent to which real behavior is driven by the financial incentives contained in compensation schemes. To address this issue, (1) we use the tournament concept as the framework, and focus on the competitive nature of mutual fund environments how to affect the managers' portfolio decision-making processes. (2) we also use the Black-Scholes option pricing model as the framework, and analyze the impact on the mutual fund managers' risk-manipulation behavior of a performance-based incentive plan. Given the asymmetric information financial markets, most investors of mutual funds can not measure the funds' risk without error, thus, agent-divergent behavior may potentially arise. In a tournament reward structure, the managers' rational attempting to maximize their expected compensation may revise the risk level or alter the composition of their portfolio during the assessment period. While there will be times when such changes don't serve the best interest of funds' investors. Our research demonstrates the following results: 1. An empirical investigation of 86 open-type mutual funds during 1995 to 1998 with the methods of test, t test and the Logistic regression shows fund managers with poor performance would become aggressive and tend to increase fund volatility in the latter part of an annual assessment period. The effect is obviously clear toward the end of the year and it is involved with the investors' myopic of the assessment to the managers' performances. 2. In our model, the bonus is similar to a call option on the funds' portfolio. Three types of incentive contracts are compared. The results show that the incentive contract with penalty can reduce managers to adversely alter the risk of the portfolio they manage. It dominates the pure incentive contract and only with a ceiling incentive contract. Questionnaires investigated by fund managers will support some hypothesis.

Made available in DSpace on 2011-05-04T12:36:23Z (GMT). No. of bitstreams: 0 Previous issue date: 2009 / OBJETIVO: Avaliar a efetividade do tratamento hospitalar do Acidente Vascular Cerebral Agudo no Sistema Único de Saúde SUS, comparando a mortalidade hospitalar ajustada entre pacientes que realizaram ou não a tomografia computadorizada. MÉTODO: A fonte de informação utilizada foi o Sistema de Informação Hospitalar do SUS (SIH-SUS). Foram selecionadas 328.087 internações ocorridas no SUS em todo o território nacional entre abril de 2006 e dezembro de 2007. As internações foram reunidas e estudadas em 4 grupos: Acidente Isquêmico Transitório (CID-10: G459); Acidente Vascular Cerebral Hemorrágico (CID-10: I60; I61 e I62); Acidente Vascular Isquêmico (CID-10: I63) e Acidente Vascular Cerebral não especificado (CID-10: I64). Foram utilizadas as mortalidades hospitalares até o sétimo e até o trigésimo dias, como medidas de resultado para comparar pacientes que realizaram e não realizaram tomografia computadorizada. RESULTADOS: Em geral os pacientes que realizaram a tomografia computadorizada apresentaram menores taxas de mortalidade hospitalar em relação àqueles que não realizaram o exame, sendo essa diferença em favor da realização do exame observada principalmente até o segundo dia de internação em todos os 4 grupos. A diferença entre os que realizaram e os que não realizaram o exame foi acentuada no grupo do Acidente Vascular Isquêmico (OR: 0,325; p>0,000), sendo que no primeiro dia o odds ratio foi de 0,021(p>0,000), em favor dos que realizaram o exame. CONCLUSÕES: Os exames de tomografia computadorizada no SUS, em geral, são realizados mais tardiamente que o recomendado pela literatura. Apesar das limitações ainda existentes na qualidade da informação diagnóstica disponível no SIH-SUS que restringiram a estratégia de ajuste de risco empregada nesse estudo, sugere-se o uso da tomografia computadorizada, o mais cedo possível, como tecnologia auxiliar no diagnóstico e tratamento do AVC. Além disso, sugere-se o emprego mais amplo de medidas de desempenho, tais como a mortalidade hospitalar aqui empregada, para o monitoramento da qualidade do cuidado prestado no âmbito do SUS. / OBJECTIVE: To evaluate the effectiveness of hospital care of the Stroke in the Brazilian Health System by comparing adjusted hospital mortality rate between patients who had done or not CT scanning. METHOD: Brazilian hospital information systems was the data source used. Three hundred twenty eight thousand and eighty seven inpatients were included in this study, covering all the Brazilian territory between April of 2006 and December of 2007. The inpatients had been grouped in 4 groups: Transient cerebral ischaemic attack, unspecified (ICD-10: G45.9); Haemorrhage Stroke (ICD -10: I60; I61 and I62); Cerebral infaction (ICD -10: I63) and Stroke not specified as haemorrhage or infarction (ICD -10: I64). Hospital mortality until seventh and the thirtieth day was used as a result measure to compare patients who had been submitted or not to Computerized tomography (CT) scanning. RESULTS: In general the patients who submitted to TC scanning presented lower hospital mortality rates in relation to those who had not done CT scanning, being this difference for the accomplishment of the examination observed until the second day of in-hospital all stroke group. The group of the ischemic stroke presented the higher difference among those who were submitted or not to Computerized tomography (CT) scanning (OR: 0.325; p>0.000). In the first in-hospital day for the stroke group the odds ratio 0.021 (p>0.000) in favor of the group who had done the CT. CONCLUSIONS: The TC scans in the Brazilian health system, in general, are used with a greater delay than the recommended in literature. This leads to a reduction of the benefits of the examination. Although the limitations in the data quality of Brazilian hospital, the use of the TC scanning, as soon as possible, is suggested as auxiliary technology in the diagnosis and treatment of the stroke. Furthermore, it is also suggested a more frequent employment of performance indicator, such as hospital mortality rate, to monitoring quality of care in Brazil.

Background: Shifting the healthcare payment system from a volume-based to a value-based model has been a significant effort to improve the quality of care and reduce healthcare costs in the US. In 2018, Massachusetts Medicaid launched Accountable Care Organizations (ACOs) as part of the effort. Constructing, assessing, and risk-adjusting quality measures are integral parts of the reform process. Methods: Using data from the MassHealth Data Warehouse (2016-2019), we assessed the loss of community tenure (CTloss) as a potential quality measure for patients with bipolar, schizophrenia, or other psychotic disorders (BSP). We evaluated various statistical models for predicting CTloss using deviance, Akaike information criterion, Vuong test, squared correlation and observed vs. expected (O/E) ratios. We also used logistic regression to investigate risk factors that impacted medication nonadherence, another quality measure for patients with bipolar disorders (BD). Results: Mean CTloss was 12.1 (±31.0 SD) days in the study population; it varied greatly across ACOs. For risk adjustment modeling, we recommended the zero-inflated Poisson or doubly augmented beta model. The O/E ratio ranged from 0.4 to 1.2, suggesting variation in quality, after adjusting for differences in patient characteristics for which ACOs served as reflected in E. Almost half (47.7%) of BD patients were nonadherent to second-generation antipsychotics. Patient demographics, medical and mental comorbidities, receiving institutional services like those from the Department of Mental Health, homelessness, and neighborhood socioeconomic stress impacted medication nonadherence. Conclusions: Valid quality measures are essential to value-based payment. Heterogeneity implies the need for risk adjustment. The search for a model type is driven by the non-standard distribution of CTloss.